Viewpoint: “It’s All in Your Head”—Medicine’s Silent Epidemic

Andy

Andy

Senior Member (Voting rights)
“It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease. As a neurologist specializing in neuropsychiatry, nothing bothers me more than overhearing medical colleagues proclaim this one-liner at the bedside or snicker about these patients during rounds. Unbeknownst to them, I also hear my patients’ version of being on the other end of this phrase and find myself constantly trying to repair the damage that these words can cause. Whether physicians like to admit it or not, medically unexplained symptoms encompass a vast terrain of clinical practice. In neurology, these symptoms fall under functional neurological disorder, but every specialty has their own variants and favored terminologies (eg, chronic fatigue syndrome, fibromyalgia). The inadequate management of this segment of medicine represents a silent epidemic that is slowly eroding patient-physician relationships, perpetuating unnecessary disability, and straining health care resources.
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Paywall, https://jamanetwork.com/journals/jamaneurology/article-abstract/2751253
Sci hub, https://sci-hub.se/10.1001/jamaneurol.2019.3043
 
It's yet another person that proposes a solution coming from deep within the same belief system that created the problem in the first place. These kinds of solutions will perpetuate the problem rather solve it.

The article has some good parts, such as the recognition that there is a huge problem, but it concludes with a link to neurosymptoms.org and the suggestion to refer to interdisciplinary management (eg, physical therapy, occupational therapy, psychotherapy). In other words, the solution is to decide that "it's psychosomatic and not our problem".
 
It is interesting that this article is written by a trainee - a fellow, or in the UK a registrar.
How does he know so much about what is wrong with his speciality.
Wouldn't one expect an article like this to come from a senior expert?

The text is very similar to something we have seen from Mark Edwards - a bit more senior bu may be not much.

I agree that there are some sensible points but the theoretical understanding is no good. and since the problem being discussed is due to a failure of theoretical understanding this doesn't bode well.

I fear that this is just something written as part of posturing to build up a practice - to make money and fame out of people with 'medically unexplained symptoms'.

Fairly soon the bot websites will be able to put something as good as this together at the press of a button. Maybe someone will then stand on a piece of paper and say 'Stop'?
 
The direct, unspoken, implication of arguments like this is that medicine has found everything there is to know, that we have simply stopped discovering things because there are none left and merely have to figure out the small details about the things that exist, which we have catalogued in full (nevermind that we keep discovering new things, even new organs, shhhhh about that).

Which is laughable and just about the most anti-scientific argument possible. May as well leave it to religion for all that this is likely to solve the problem. And so remarkable that the proposed "solution" to the problem is literally the reason why the problem persists at all, that those unexplained health problems all share the feature of having been starved of research funding and serious efforts, leaving everything into the hands of the very field of medicine that has so far produced the least results, if any. Don't look, won't find. This is pretty much universal.

The solution actually exists and it's the one that has always succeeded: research. It's expensive, it's boring, it's hard. But it works 100% of the time, given enough time, resources and skill. The current problem is caused by this exact argument here being used time and time again by people who were certain that everything had been figured out at the time, and again, and again.

Somewhere around 1900, the director of the US patent office stated that in his mind scientific discovery had ended, that we knew everything humanity would ever know about nature and the universe and as such suggested that his office be closed since there was no need for further patents at this point, science had run its course. This is the exact argument right here. Dumb as it ever was. Wrong as it ever will be.
 
The very first sentence :

"It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease.
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Can I rephrase that to make it more honest?

"It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms the doctor is unable to diagnose, or is insufficiently experienced to diagnose, or the doctor doesn't want to spend time and money on the patient doing (for example) exploratory surgery, or where the disease or illness being looked for is rare, or unexpected because of the patient's appearance or age, and by looking for horses not zebras the doctor misses the herd of zebras which have just filled up his surgery.
 
I suspect that what patients actually hear more often than "It's all in you head" is something along the lines of "Maybe it's all in your head," or "Do you think it's possible that it's all in your head?"

It's easy to dismiss a doctor who gives you an absolute like "It's all in your head." By posing the idea as a possibility, your own self-doubt is being enlisted, which is likely to be more persuasive to you than a diagnosis which is based entirely on a process of elimination exclusively composed of negative results on standard tests.

At least, that might be the working theory. When a doctor said to me, "Maybe it's all in your head," my internal monologue could be summed up as "Waiter! Check, please!"
 
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A person born without legs can have pain in their ankle. I am wary to underestimate that relevance to CFS.

The idea of a new grad doing this is hilarious to me: the MCAT is now like half organic chemistry, half "how woke are you?". I know old school docs like this though.
 
beverlyhills said:
A person born without legs can have pain in their ankle.
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I very much doubt this. Could you please provide a source? Thanks.

ETA: Never mind, I found one, even by V.S. Ramachandran.
Seems like our brain may have "an innate, hard-wired template for body image that is independent of what we see and feel".
 
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